• r »t4 TREATMENT OF NON-STRANGULATED TNGUINAL HERNIA 



(b) The application of a clam. This is very generally practised, 

 and resembles the covered method of castration. The hernia is 

 reduced and the clam applied as high, that is, as near to the inguinal 

 ring, as possible, and over the tunica vaginalis refiexa and spermatic 

 cord. In order to be able to apply the clam very high it has been 

 recommended to give it a bent form, but this is not desirable, because 

 the centre portion does not press sufficiently on the tunica vaginalis. 

 A simpler and more effectual way of closing the tunica vaginalis 

 above the clam is to give a half turn, which may later be made a 

 complete one, to the tunica vaginalis and spermatic cord before 

 applying the clam. 



Recurrence of the hernia is prevented by the formation of 

 adhesions between the two vaginal coverings of the cord ; but where 

 the abdominal ring is large, partial recurrence may follow operation, 

 and sometimes in the foal owing to tissue weakness, the external 

 tunica vaginalis ruptures above the clam. Though the danger of 

 post-operative recurrence is certainly decreased by twisting the cord 

 and tunica vaginalis, it is not entirely removed, and therefore the 

 technique has been somewhat modified by different operators. The 

 operation should be performed aseptically and under chloroform. 

 A short but carefully disinfected clam is selected, and an incision 

 made through the skin, large enough to allow the clam to be pushed 

 to the bottom of the wound, and to be secured just under the external 

 inguinal ring. The skin is then brought over it and sutured, thus 

 retaining the clam in the wound. If neither fever, swelling, nor 

 other disturbance is marked during the next few days, the clam is 

 allowed to remain in position for a week or longer. On removal, 

 healthy granulations will be found unaccompanied by pus formation, 

 and usually the wound heals in a short time under antiseptic pre- 

 cautions. 



Stockfleth operated in a similar way. He drew T the lappets of 

 skin over the clam, by means of purse-string sutures, but loosened 

 the latter next day, and applied a ligature around the tunica vaginalis 

 and above the clam. If this be not done, it is well to fasten the 

 clam to the neighbouring skin by a ligature. 



Sorensen and others apply a ligature above the clam for a similar 

 purpose. The clam is removed next day, but the ligature is left 

 in position until it falls off. 



The clam must not be removed too soon. The longer it remains 

 the better the union between the surfaces of the vaginal tunics. 

 Jessen found three days too little, and in his later cases left the clam 

 on for five days. In the above operation the clam may remain in 



